Why I will never be an organ donor

From the Washington Post, March 18th, 2007:

New trend in organ donation raises questions

As alternative becomes more frequent, doctors worry it puts donors at risk

The number of kidneys, livers and other body parts surgeons are harvesting through a controversial approach to organ donation has started to rise rapidly, a trend that is saving the lives of more waiting patients but, some say, risks sacrificing the interests of the donors.

Under the procedure, surgeons are removing organs within minutes after the heart stops beating and doctors declare a patient dead. Since the 1970s, most organs have been removed only after doctors declared a patient brain dead.

Federal health officials, transplant surgeons and organ banks are promoting the alternative as a way to meet the increasing demand for organs and to give more dying patients and their families the solace of helping others.

Some doctors and bioethicists, however, say the practice raises the disturbing specter of transplant surgeons preying on dying patients for their organs, possibly pressuring doctors and families to discontinue treatment, adversely affecting donors' care in their final days and even hastening their deaths.

Nevertheless, the number of these donations is on the rise. It more than doubled from 268 in 2003 to at least 605 in 2006, enabling surgeons to transplant more than 1,200 additional kidneys, livers, lungs, hearts and other organs.

[...]

The trend is expected to accelerate this year. For the first time, the United Network for Organ Sharing, which oversees organ procurement, and the Joint Commission on Accreditation of Healthcare Organizations, which accredits hospitals, are requiring all hospitals to decide whether to allow the practice. In response, medical centers are scrambling to develop policies, sometimes sparking intense debate, especially at children's hospitals.

"It's an example of pushing the envelope to get more organs," said Stuart J. Youngner, a bioethicist at Case Western Reserve University. "Whenever we do that, we tend to step on various traditional social taboos."

[...]

Once the decision has been made, a transplant team waits nearby so surgeons can begin removing organs soon after the heart stops. Because the heart can sometimes restart spontaneously, doctors wait a few minutes after pronouncing death before allowing the surgeons to begin. If the heart does not stop quickly, usually within an hour, the procedure is aborted and the patient is taken back to his or her room until death comes.

The practice was the norm before brain death became the standard for pronouncing death in the early 1970s and surgeons began keeping the donor's body functioning with life-support machinery until transplantation could begin. When surgeons resurrected what was then called "non-beating heart" donation in the 1990s, critics called it ghoulish and said it raised a host of ethical questions. Some called it tantamount to murder.

The National Academy of Sciences' Institute of Medicine examined the practice, however, and concluded that it is ethical as long as strict guidelines are followed, including making sure that the decision to withdraw care is independent of the decision to donate organs and that surgeons wait at least five minutes after the heart stops.

[...]

While some doctors and ethicists who initially questioned the practice have become more comfortable with the procedure, others remain troubled.

"The image this creates is people hovering over the body trying to get organs any way they can," said Michael A. Grodin, who directs Boston University's Bioethics and Human Rights Program. "There's a kind of macabre flavor to it."

Some say the practice can interfere with patients' dying peacefully, surrounded by loved ones, and can deny the family sufficient time to grieve. Many hospitals have responded by withdrawing life-support devices and other care in the intensive-care unit or allowing families to accompany loved ones to the operating room so they can be at the bedside when death occurs.

But many experts remain concerned and worry that the practice blurs the definition of death.

"The person is not dead yet," said Jerry A. Menikoff, an associate professor of law, ethics and medicine at the University of Kansas. "They are going to be dead, but we should be honest and say that we're starting to remove the organs a few minutes before they meet the legal definition of death."

In response to such concerns, most doctors wait five minutes after the heart stops before pronouncing patients dead. But doctors at some hospitals wait three minutes, others two. In Denver, surgeons at Children's Hospital wait 75 seconds before starting to remove hearts from infants, to maximize the chances that the organs will be useable.

[...]

In addition to giving DCD donors morphine, valium and other drugs to make sure they do not suffer as life support is withdrawn, doctors often insert a large tube into an artery and inject drugs such as the blood thinner heparin to help preserve the organs. Some say those measures may hasten death.

Up until the advent of heart transplants, death was always defined as "when the heart stops beating." "Donation after cardiac death" (DCD) was replaced with DBD or "donation after brain death" in the early 1970s a few years after the South African surgeon, Christiaan Barnard, did the first heart transplant and the practice became widespread. Kidney transplants had almost become routine by then but, unlike hearts, kidneys could be packed in ice and did not need to be used immediately. Hearts need to be as fresh as possible and the standard practice was to remove the heart as soon as the donor was declared brain-dead even if the heart was still beating and transplant it into the donee immediately.

In California Organ Donor Cards are given out automatically every time you renew your driver's licence. I always refused to sign and carry one because, in the 30 years that I worked in hospital pharmacies, I heard too many horror stories such as donors opening their eyes just as their hearts were being cut out. I figured there is seldom smoke without fire and that was even before I saw my first transplant surgery. I'll tell you about that.

20 years ago the hospital that I worked at decided to do a very new procedure - liver transplants. A famous surgeon from Spain was hired and specially trained OR nurses were recruited. In those days liver transplant surgery could take up to 30 hours so it was always done at night when there was no rush to do as many surgeries as possible in the same OR. At that time I was doing my 8-year stint on night-shift. I was one of two people in the pharmacy on "graveyard shift" as it is commonly known.

Most transplant surgery requires a lot of IV drugs which we used to make up ahead of time and deliver to the OR but liver transplants were not yet routine and the surgeon did not always know exactly which drugs to order ahead of time. So we often had to make specialized IV drips which were not available commercially and deliver them to the OR during surgery. I had gotten used to the idea that we had to make antibiotic drips for donors to make sure that they did not develop infections prior to having their organs harvested but one night the surgeon ordered a dilaudid drip.

Most of the injectable opiates are made in IV bags commercially but not dilaudid. Apparently the donor was allergic to all opiates like morphine and demerol but not to dilaudid. Making antibiotic or heparin drips for soon-to-be-dead donors was bizarre enough but I was quite rattled by the idea that the donor needed a painkiller. I went to deliver the IV drip to the OR. Because dilaudid is a narcotic it must be delivered to and signed for by the doctor who ordered it. I had to wait (behind a glass partition because I was not sterile) for one of the assisting surgeons to do so. I watched until the surgeon came to get the dilaudid drip.

The OR was the largest one in the hospital but it was crowded. There were surgeons and nurses surrounding the donor harvesting his organs such as corneas and kidneys. The Spanish surgeon had just finished cutting the diseased liver out of the donee. As soon as all of the donor's organs (all except the heart - that had to be beating during the removal of the liver) had been harvested by the assisting surgeons, the liver was ready to be removed. Removing the liver took many hours because of the need to keep the blood vessels intact. That's what the dilaudid drip was for - to make sure that the donor did not feel any pain during the removal of his liver.

I knew that the donor had been pronounced brain-dead and was only breathing because of a respirator but watching his chest rise and fall with each breath as his organs were removed shook me up and made me even surer that I would never sign up to be an organ donor.

The new trend of using "heart death" as the definition of death instead of "brain death" is far too iffy for my tastes. If the brain is still alive, the heart can start beating even after it has stopped for a while. Of course after four minutes there will be brain damage due to lack of oxygen but I think I still would prefer to live with brain damage than to open my eyes and see a surgeon lifting my heart out of my rib-cage.

And now I'm going to do some transplanting of my own but I'm sticking to transplanting plants in my garden.